Mood disorders in menopause
Menopause constitutes a moment of crisis which, similarly to other stages of female life such as adolescence and pregnancy, requires physiological, psychological and relational adaptations. If the production of estrogen decreases, the quantities of serotonin, endorphins and dopamine also decrease and consequently there is a significant change in mood.
Menopause is a physiological stage in every woman’s life. It occurs on average around 50 years of age, following the cessation of menstrual cycles following the loss of ovarian follicular function. In this delicate phase of the female life cycle, there is also an interruption in the production of estrogen and progesterone. Menopause constitutes a moment of crisis which, similarly to other stages of female life such as adolescence and pregnancy, requires physiological, psychological and relational adaptations. According to the classic stereotype, motherhood and the adolescent crisis have an evolutionary and creative meaning while menopause is more a mourning experience due to the loss of fertility.
During menopause the body produces less estrogen. Specifically, during the climacteric (premenopausal period) the ovaries, producing estrogen and progesterone, respond less and less to the stimuli of the hormones FSH and LH produced by the pituitary gland, which is located at the base of the head. These hormonal changes send the hypothalamus, that part of the brain that also manages the reaction to emotions, haywire. In fact, estrogens, in addition to regulating the menstrual cycle, also stimulate the production of:
If the production of estrogen decreases, the quantities of serotonin, endorphin and dopamine also decrease, as a consequence there is a noticeable change in mood.
The transition to menopause is however a gradual process: hormonal fluctuations begin several years before the disappearance of the cycle and give rise to menstrual irregularities, changes in the intensity of the flow, as well as various symptoms and above all a progressive reduction in the fertility.
This phase has a very variable duration, it can last up to ten years; it is generally the most symptomatic phase and is called perimenopause.
The symptomatology of menopause is somewhat varied, as this phase is characterized by a highly subjective and often difficult experience.
The effects of menopause are in fact very variable and depend on genetic predisposition, personal history, lifestyle, psychosocial factors and socio-cultural environment.
Menopause is often experienced dramatically by women because it is identified with the onset of aging.
Some women, for the possibility of living a freer sexuality, free from the fear of pregnancy, or for the disappearance of perhaps heavy and disabling menstrual symptoms, welcome this period positively. These women show a positive attitude towards menopause, considering it not only a physiological transition, but also an opportunity for existential budgets, further maturation and achievement of objectives.
Other women, on the other hand, attribute to the onset of menopause a meaning of loss and impoverishment, aggravated by the presence of symptoms and manifestations that interfere with the quality of life.
To all this are added the social and cultural factors, in particular the meaning attributed to the phase of menopause. In some cultures, in fact, the cessation of fertility corresponds to a moment of social growth and puts the woman in a privileged position, in which she enjoys greater consideration and respect, in western society, on the contrary menopause is often synonymous with loss of femininity and aging.
From a purely hormonal point of view, estrogens condition the quality of life, as their deficiency affects sexual desire and favors the appearance of vasomotor, genitourinary, osteoarticular and psychoemotional symptoms.
One of the most annoying phenomena, indicating an estrogen deficiency, is represented by the appearance of hot flashes. Most often they appear at night, causing significant sweats that interfere with the quality of sleep and then affect general well-being, even during the day.
The hormonal drop also affects the reproductive system, with the appearance of dryness and vaginal atrophy, which can make sexual intercourse painful and difficult. Furthermore, when the level of estrogen decreases, the production of collagen and elastin also decreases: the skin can become thinner, dry and lose elasticity.
In addition to these purely physical effects, fatigue, headache, difficulty concentrating and memory may also occur near menopause. Insomnia and sleep and mood disorders are also frequent, with anxiety, irritability and depression.
Estrogens, as well as androgenic hormones, certainly have the effect of a brain “fertilizer”; however, there is no reliable evidence for a direct link between their reduction and the appearance of depression and mood disorders.
Various hypotheses have been formulated to explain this relationship. For example, estrogen deficiency, causing hot flashes and night sweats that interfere with sleep, which in turn is linked to mood swings, would be indirectly responsible for the symptoms of the psychoemotional sphere.
According to psychosocial theory, the explanation would instead be to be found in external factors and biological changes. The depressive symptoms would therefore be related to various stressors: possible health problems, the care of children, the home, elderly parents or ever-increasing job requests, difficulties with the couple or in the relationship with the partner, problems with sons.
All these stressful factors, the low level of social support and physical problems can be closely related to the onset of depression during this period.
From an epidemiological point of view, women are generally more exposed to depression than men: the female sex is affected in more than double percentage.
In addition to this, recent studies have shown that over 7% of women between 55 and 75 years of age develop a depressive disorder.
The lifetime prevalence for major depressive disorder is 10.2% in women versus 5.2% in men; for the dysthymia of 5.4% against 2.6% and even more marked is the female preponderance for atypical depression and seasonal depressive disorders (Kessler, McGonagle, Swartz et al., 1993; World Health Organization Kobe Center, 2005; Niolu, Ambrosio, Siracusano, 2009).
Different hypotheses explain the greater prevalence of depression in women than in men:
According to some studies, gender differences are also found in depressive symptoms. In fact, it emerges that women display the picture of atypical depression with greater statistical prevalence. The female gender also has greater psychiatric comorbidities for anxiety disorders, somatoform disorders and bulimia; differently in humans there is a greater association with alcohol and substance abuse and obsessive compulsive disorder (Khan, Broadhead, Schwartz, Koltz, Brown, 2005).
In more detail, some epidemiological studies have shown that psychosocial stressors are associated with an increased risk for the development of subclinical depressive symptoms and a greater depressive onset during the menopausal transition and their impact is greater than that of the menopausal state of per se (Lanza di Scalea, Niolu, Siracusano, 2010).
It has been known for several years that women have a higher risk of developing a depressive disorder during the postpartum due to hormonal change, however there is still little knowledge about the depressive risk associated with the period of transition to menopause.
To date, even from a clinical point of view, the recommendations regarding the diagnosis and treatment of this type of depression have been somewhat lacking.
Regarding the association between symptoms of perimenopause and depressive disorder, according to the scientific literature, symptoms such as hot flashes and sleep disturbances begin at this time and can coexist and overlap with the symptoms of depression. Particularly when hot flashes occur during the night, the so-called “night sweats”, sleep can be interrupted; persistent sleep disturbances caused by this symptom may contribute to the development or exacerbation of depressive symptoms.
However, the diagnostic process is particularly difficult because the causes of depression can be difficult to identify, moreover many times the experienced symptoms do not meet the criteria for a full diagnosis of depression. Even mild depressive symptoms, however, can lower the quality of life, what appears really important so it is a detailed analysis of the symptoms to reach a diagnosis and identify the best possible cure.
In this regard, a team of experts recently convened by the North American Menopause Society and the Network on Depression Centers Women and Mood Disorders Task Group and approved by the International Menopause Society has drafted the first guidelines, published in the Journal of Women’s Health for the evaluation and the treatment of depression during perimenopause.
The conclusions reached by the experts for the drafting of the guidelines allow us to affirm that:
In conclusion, anxiety and depression are therefore common in menopausal women, but there is no clear evidence that the biological phase itself increases the risk of clinically significant mood disorders, except in women with predisposing risk factors, such as :